Advance Directives. Making your health care choices known if you can't speak for yourself.

Advance Directives Making your health care choices known if you can't speak for yourself.

ADVANCE DIRECTIVES Making your health care choices known if you can t speak for yourself This booklet contains Advance Directive forms and general information about making Advance Directives. It is provided courtesy of Bryan Medical Center of Lincoln, Nebraska. For more information or to receive additional copies, call 402-481-3355. You may complete an Advance Directive before, during your hospital stay or wait until you are back in your own home. It is highly recommended that you take time to read this information, and discuss your wishes with family and loved ones before completing an Advance Directive. If you are a patient at the medical center and desire further assistance in completing an Advance Directive, please tell your nurse.

General Information about Advance Directives What are Advance Directives? Advance Directives are legal documents stating your choices about medical treatment or naming the people you want to make these decisions if you are unable to make them for yourself. In Nebraska, there are two types of Advance Directives: the Power of Attorney for Health Care and the Rights of the Terminally Ill Declaration (sometimes called the Living Will ). It is your right as an adult citizen of Nebraska to sign either or both of them. If recovery from a severe medical condition seems unlikely, some patients do not want the burden of continued treatment, but other patients might choose to continue treatment. Your Advance Directive is one way of helping to make sure your own individual values and choices will be respected when you are not able to make your own medical decisions. By completing Advance Directives and talking with your physician and family about your decisions, you can guide the direction of your future care. What is Informed Consent? It is your right as a competent adult patient to consent to or to reject medical or surgical treatment. Your physician will tell you about your medical condition and options for treatment. He or she will talk about the benefits, risks and consequences of starting, stopping or withholding treatment and about other treatment options you may have. The decisions you make should be truly your own, based on what you believe is best. What happens if I don t have an Advance Directive? The presence or absence of an Advance Directive will not prejudice the medical attention you receive. If you are unable to make your own medical decisions and you do not have an Advance Directive, your physician and other health care providers usually ask family members or close friends about your treatment wishes. However, if there is disagreement about what should be done, physicians and your health care facility may seek assistance from the Hospital Ethics Committee, or they may ask the court to appoint a legal guardian to make medical decisions for you. 1

How do I make Advance Directives? In order to make an Advance Directive, you must be an adult. In Nebraska, this means you must be 19 years old or older. If you are not yet 19 but are married (or have been married), you are an adult. To make an Advance Directive, read the instructions in this booklet carefully. Then read the Advance Directive forms. Discuss the forms and instructions with your family and your physician. Talk about your treatment options and your feelings, beliefs and values. Then complete the forms according to instructions. Nebraska law does not require you to consult a lawyer to make Advance Directives, although you may find it helpful to visit with a lawyer about making your Advance Directives. When you have filled out your Advance Directives, you must sign and date them in front of witnesses or a notary public. This protects you. The signature of witnesses or a notary shows that no one forced you to sign Advance Directives or signed your name for you. Witnesses should be people who know you, but who are not related to you (by blood, marriage or adoption). You cannot choose anyone who is entitled to any portion of your estate. Your physician cannot be a witness. Your attorney-in-fact or your successor attorney-in-fact cannot be a witness. Anyone employed by your life or health insurance companies cannot be a witness. Only one of the witnesses can be employed by the hospital or care provider where you are a patient or resident. How much do Advance Directives cost? There is no cost to make Advance Directives. Just follow the instructions in this booklet. If you prefer to use a lawyer to make your Advance Directives, then there may be a charge for this service. Can Advance Directives be changed? You can cancel or change your Advance Directives at any time. To cancel an Advance Directive, destroy the original copy. Tell your physician and family members (whoever has a copy) and your health care facility that you have canceled the Advance Directive. To change an Advance Directive, complete a new form and make sure it is signed, dated and witnessed or notarized. This can be done at any time as long as you are competent to make your own medical decisions. 2

When do Advance Directives take effect? Advance Directives become legal documents when you sign and date the completed forms and have them witnessed or notarized. It is important to remember that your Advance Directives will not be used as long as you are able to make your own medical decisions and give informed consent. If you can t make your own medical decisions (either temporarily or permanently), your Advance Directives take effect. If you wish, specify in your Advance Directives that a determination that you are incapable of making health care decisions must be confirmed by a second physician. Will my Advance Directives be followed? Yes, as long as they are in keeping with the laws of Nebraska. When you become a patient or resident, your healthcare facility will ask for copies of your Advance Directives which will become a part of your medical record. If your healthcare providers cannot follow the instructions in your Advance Directives for any reason, they must tell you and help arrange for your transfer to another care provider or facility. Will my Nebraska Advance Directives be honored in another state? Laws about Advance Directives are different in each state. So, if you plan to spend more than just a little time in another state, you may wish to sign Advance Directive forms for that state. Making Advance Directives in another state does not invalidate your Nebraska Advance Directives. Are Advance Directives from another state valid in Nebraska? Advance Directives that comply with another state s laws will be honored in Nebraska if they comply with Nebraska law. Must an Advance Directive be renewed? No. Once you have signed and dated your Advance Directives and had them properly signed or notarized, they remain in effect for an indefinite period of time (unless you cancel or change them). However, it is a good idea to review your Advance Directives periodically, especially if there have been important changes in your medical condition or family situation. What should I do with my Advance Directives? When you have signed and dated your completed Advance Directives and had them witnessed or notarized, keep the original documents in a safe and convenient place but not in a safe deposit box. Give copies to your attorney-in-fact, to family members or close friends and to your physician and tell them where the originals are kept. You also may want to give copies to other people, such as your clergy person and your lawyer. Keep a card in your wallet that shows you have Advance Directives. A wallet card is provided at the back of this booklet. 3

Information about the Power of Attorney for Health Care What is a Power of Attorney for Health Care (PAHC)? A PAHC is a legal document that gives the person you designate as your attorney-in-fact the power to make health care decisions for you when you are temporarily or permanently unable to make decisions for yourself. Usually people choose their spouse or another family member, a clergy person or a close friend. Your attorney-in-fact must be an adult and should be someone who knows you well and respects your decisions about medical treatment. Discuss your decisions, wishes and beliefs with the person you choose to make sure he or she accepts the responsibility of making medical decisions for you. The person you designate has a duty to act consistently with your desires as stated in your PAHC or otherwise made known by you. If your wishes are unknown, he or she must act in your best interests. The person you designate has the right to withdraw from this duty at any time. You cannot appoint any of these people as your attorney-in-fact: Your physician, An employee of your physician (unless he or she is related to you by blood, marriage or adoption), An owner, operator or employee of the health care facility in which you are a patient or resident (unless he or she is related to you by blood, marriage or adoption). You also can appoint a successor attorney-in-fact to be an alternate decision maker if your attorney-in-fact is unavailable. He or she then would have the same powers as your attorney-in-fact. Neither your attorney-in-fact nor your successor attorney-in-fact can be held liable for treatment decisions they make in good faith or for the cost of any treatment authorized just because he or she is your attorney-in-fact. Is a Power of Attorney for Health Care (PAHC) the same as a Power of Attorney? Power of Attorney documents usually refer to financial decisions but some may contain a section on health care decisions as well. A PAHC deals only with health care and does not give your attorney-in-fact the power to make financial decisions on other non-medical decisions for you. 4

Should I have both a PAHC and a Living Will? A PAHC takes effect whenever you are unable to make your own medical decisions. In your PAHC, you may give your attorney-in-fact instructions about what you do and do not want done for you. Following your guidelines, your attorney-in-fact is able to make decisions in all types of health care situations, even those you may not have been able to anticipate. For this reason, it is important to choose someone you trust as your attorney-in-fact. Some people may not have close family or know anyone they would feel comfortable naming as their attorney-in-fact. A Living Will may be helpful for them. A Living Will takes effect only when you have a terminal illness or are in a persistent vegetative state and cannot speak for yourself. What instructions should I give my attorney-in-fact? Your instructions should reflect your own personal values, beliefs and faith. Your instructions should address the use of life-sustaining procedures, such as: A mechanical ventilator (respirator), which helps breathe for you; Kidney dialysis, which is used if your kidneys can t function; Cardiopulmonary resuscitation (CPR), which is used if your heart or breathing stops; or Artificially administered nutrition (food) and hydration (fluids). Life-sustaining procedures do not provide a cure for a terminal illness. They may prolong the process of dying. In this booklet you will find two PAHC forms. They are identical except that one form has blank spaces in which you can write your instructions, limitations and decisions about life-sustaining treatment and/or artificially administered nutrition and hydration. Because some people are not sure what instructions to write, another form is provided that has examples of instructions. If these instructions are satisfactory to you, you can sign this form instead. Or you can use these instructions as examples in writing your own instructions. Although you are not obligated to give instructions in your PAHC, your attorney-in-fact will not have the authority to consent to the withholding or withdrawal of life sustaining procedures or artificially administered nutrition and hydration unless you give him or her that authority. What is a Living Will? A Living Will (known officially in Nebraska as the Rights of the Terminally Ill Declaration) is a legal document that takes effect if you have a terminal illness or are in a persistent vegetative state and cannot make your own medical decisions. This document tells your physician and health care facility that you do not want life-sustaining procedures. It also affirms your decision to accept or continue any treatments or procedures that are given for the purpose of making you comfortable or alleviating pain. 5

Information about the Living Will Rights of the Terminally Ill Declaration Is a Living Will the same as a will or a living trust? No, they are not the same. A Living Will takes effect while you are alive but a will takes effect only after your death. Wills and living trusts assure the distribution of your financial assets but say nothing about your medical wishes and decisions. What is an incurable, irreversible condition? An incurable and irreversible condition is a terminal disease or medical condition that has no presently known medical cure and that is expected to lead to death within a fairly short time, usually several weeks or months. What is a persistent vegetative state? A persistent vegetative state is a condition of irreversible unconsciousness or permanent coma in which a patient is completely unaware of self, loved ones, events or surroundings. Persistent means that this condition cannot change, and presently there is no known medical cure. When does a Living Will take effect in Nebraska? A Nebraska Living Will takes effect only when: You have been diagnosed by a physician to have an irreversible and incurable condition or a persistent vegetative state. You are not able to make your own medical decisions. In addition, a Nebraska Living Will cannot take effect if you are pregnant and it is probable that the unborn child will develop to the point of a live birth with the continued use of life-sustaining procedures. 6

NEBRASKA POWER OF ATTORNEY FOR HEALTH CARE I appoint, whose address is, and whose telephone number is ( ), as my attorney-in-fact for health care. I appoint, whose address is, and whose telephone number is ( ), as my successor attorney-in-fact for health care. I authorize my attorney-in-fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions. I have read the warnings stated in this document and understand the consequences of executing a power of attorney for health care. I direct that my attorney-in-fact comply with the following instructions or limitations: I direct my attorney-in-fact to authorize the withholding or withdrawal of any medical procedure, treatment or intervention that uses mechanical or other artificial means to sustain, restore, or supplant a spontaneous vital function which would, when applied to me, serve only to prolong my dying process or persistent vegetative state. I direct that my attorney-in-fact comply with the following instructions on life-sustaining treatment: If I should lapse into a persistent vegetative state or have an incurable and irreversible condition that, without the administration of life-sustaining treatment which could include but is not limited to artificially administered nutrition and hydration, will, in the opinion of my attending physician, serve only to prolong my dying process or persistent vegetative state, I direct my attorney-in-fact to authorize the withholding or withdrawal of life-sustaining treatment that is not necessary for my comfort or to alleviate pain. I direct that my attorney-in-fact comply with the following instructions on artificially administered nutrition and hydration: I direct my attorney-in-fact to authorize the withholding or withdrawal of artificially administered nutrition and hydration which would, when given to me, serve only to prolong my dying process or my persistent vegetative state. 7

I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY ATTORNEY-IN-FACT, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN. DECLARANT SIGNATURE Signed this day of, 20 Signature Social Security Number Printed Name Printed Address DECLARATION OF WITNESSES We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care in our presence, that the principal appears to be of sound mind and not under duress or undue influence, and that neither of us nor the principal s attending physician is the person appointed as attorney-in-fact by this document. Witnessed By: (Signature of Witness/Date) (Signature of Witness/Date) (Printed Name of Witness) (Printed Name of Witness) - OR - NOTARY (You may sign this document before a notary public instead of having it witnessed above.) State of Nebraska ) ) ss. County of ) Notary Public My commission expires 8

NEBRASKA POWER OF ATTORNEY FOR HEALTH CARE I appoint, whose address is, and whose telephone number is ( ), as my attorney-in-fact for health care. I appoint, whose address is, and whose telephone number is ( ), as my successor attorney-in-fact for health care. I authorize my attorney-in-fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions. I have read the warnings stated in this document and understand the consequences of executing a power of attorney for health care. I direct that my attorney-in-fact comply with the following instructions or limitations: I direct that my attorney-in-fact comply with the following instructions on life-sustaining treatment: I direct that my attorney-in-fact comply with the following instructions on artificially administered nutrition and hydration: 9

I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY ATTORNEY-IN-FACT, MY PHYSICIAN OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN. DECLARANT SIGNATURE Signed this day of, 20 Signature Social Security Number Printed Name Printed Address DECLARATION OF WITNESSES We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this power of attorney for health care in our presence, that the principal appears to be of sound mind and not under duress or undue influence, and that neither of us nor the principal s attending physician is the person appointed as attorney-in-fact by this document. Witnessed By: (Signature of Witness/Date) (Signature of Witness/Date) (Printed Name of Witness) (Printed Name of Witness) - OR - NOTARY (You may sign this document before a notary public instead of having it witnessed above.) State of Nebraska ) ) ss. County of ) Notary Public My commission expires: 10

RIGHTS OF THE TERMINALLY ILL DECLARATION (NEBRASKA LIVING WILL DECLARATION) If I should lapse into a persistent vegetative state or have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Rights of the Terminally Ill Act, to withhold or withdraw life-sustaining treatment that is not necessary for my comfort or to alleviate pain. DECLARANT SIGNATURE Signed this day of, 20 Signature Social Security Number Printed Name Printed Address DECLARATION OF WITNESSES We declare that the principal is personally known to us, that the principal signed or acknowledged his or her signature on this Rights of the Terminally Ill Declaration in our presence and that the principal appears to be of sound mind and not under duress or undue influence. Witnessed By: (Signature of Witness/Date) (Signature of Witness/Date) (Printed Name of Witness) (Printed Name of Witness) - OR - NOTARY (You may sign this document before a notary public instead of having it witnessed above.) State of Nebraska ) ) ss. County of ) Notary Public My commission expires: 11

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What Should I Do With My Advance Directives? You should send a completed copy to the people who are likely to be asked about your choices. For your records, you can write below the names of the people who have a copy of your Advance Directives or who know what kind of health care you want. Family members Attorney-in-fact for health care Physician Other health care provider(s) Attorney Clergy person Hospital Other health care facility NOTICE TO HEALTH CARE PROVIDERS Name Social Security Number I have a living will. I have a power of attorney for health care and my attorney-in-fact is: Name Phone (day) (evening) (over) FOLD Copies of this document have been given to: Phone Phone Phone Bryan Medical Center 1600 S. 48th St. Lincoln, NE 68506-1299 402-481-1111 bryanhealth.org Clip

Bryan Medical Center Bryan East Campus 1600 S. 48th St. Lincoln, NE 68506-1299 402-481-1111 bryanhealth.org Form 354, (Rev. 03/18) Bryan Medical Center Bryan West Campus 2300 S. 16th St. Lincoln, NE 68502-3704 402-481-1111